Entrapment neuropathies in diabetes mellitus

Presurgical management of ulnar nerve entrapment in patients with and without diabetes mellitus

Diabetes mellitus (DM) is a risk factor for the development of ulnar nerve entrapment (UNE). Differences in surgical outcomes for UNE between patients with and without DM have been reported, but studies on presurgical management are scarce. This study aimed to evaluate the presurgical management of UNE in patients with (DM diagnosis < 2 years of UNE diagnosis) and without DM regarding the level of care for diagnosis and the proportion that proceeds to surgery. Data from 6600 patients with UNE between 2004 and 2019 were included from the Skåne Health Care Register (SHR) and cross-linked with data from the Swedish National Diabetes Register (NDR). The group with UNE and DM was compared to the group with UNE without DM and prevalence ratios were calculated using Cox regression analysis. Patients with DM more often got their first UNE diagnosis in secondary care than in primary care (643/667, 96% vs. 5361/5786; 93%). Patients with and without DM, regardless of the type of DM, presence of retinopathy, or HbA1c levels, were surgically treated for UNE to the same extent (258/667, 39% of patients with DM vs. 2131/5786, 37% of patients without DM). The proportion of surgically treated was significantly lower among patients diagnosed with UNE in primary care compared to secondary care (59/449, 13% vs. 2330/5786, 38%). Men were more often surgically treated than women (1228/3191, 38% vs.1161/3262 36%). Patients with UNE and DM are surgically treated to the same extent as patients with UNE but without DM and are more likely to be diagnosed in specialized care.

Objective Evidence That Nerve Decompression Surgery Reduces Neuropathic DFU Recurrence Risk to Less than 5%

Significance: Despite 20 years of research and new treatment methods, diabetic foot ulcer (DFU) remains a common problem with frequent recurrences and complications. Recent Advances: There are reports that nerve decompression (ND) surgery has been observed to produce significantly fewer DFU recurrences than standard of care (SOC). The explanation of this apparent superiority has not been understood. Critical Issues: Microcirculation is understood to be involved in diabetic peripheral neuropathy (DPN) and DFU. There is an underappreciation of the participation in DPN of entrapment neuropathy (EN) due to nerve swelling and impingement in fibro-osseous tunnels. Reducing c-fiber compression in EN by ND generates recovery of subepidermal capillary flow. ND studies have found improved neuromuscular function and epidermal microcirculation phenomena, including chronic capillary ischemia (CCI) and pressure-induced vasodilatation (PIV). There is no current therapy recommended for impaired microcirculation. Clinical and animal evidence has demonstrated that release of locally compressed peripheral nerves improves the epidermal microcirculation which is under sympathetic control. Future Directions: Using epineurolysis to relieve nerve compressions is a physiology-based therapeutic intervention and provides the scientific foundation clarifying how ND reduces DFU recurrence risk. Incorporating ND with current SOC treatments could improve DFU recurrence risk, hard-to-heal ulcers, neuroischemic wounds, amputation risk, and the resulting costs to society. More studies using ND for DFU, especially evidence-based medicine Level I studies, are needed to confirm these preliminary outcomes.

Surgery for carpal tunnel syndrome in patients with and without diabetes-Is there a difference in the frequency of surgical procedures?

Carpal tunnel syndrome (CTS) occurs more often among individuals with diabetes. The aim of this retrospective observational registry study was to examine whether individuals with diabetes and CTS are treated surgically to the same extent as individuals with CTS but without diabetes. Data on CTS diagnosis and surgery were collected from the Skåne Healthcare Register (SHR). A total of 35,105 individuals (age ≥ 18 years) diagnosed with CTS from 2004-2019 were included. Data were matched to the Swedish National Diabetes Register (NDR. Cox regression models were used to calculate the risk of the use of surgical treatment. Of the 35,105 included individuals with a CTS diagnosis, 17,662 (50%) were treated surgically, and 4,966 (14%) had diabetes. A higher number of individuals with diabetes were treated surgically (2,935/4,966, 59%) than individuals without diabetes (14,727/30,139, 49%). In the Cox regression model, diabetes remained a significant risk factor for surgical treatment (PR 1.14 (95% CI 1.11-1.17)). Individuals with type 1 diabetes were more frequently treated surgically (490/757, 65%) than individuals with type 2 diabetes (2,445/4,209, 58%). There was no difference between the sexes and their treatment. The duration of diabetes was also a risk factor for surgical treatment in diabetes type 2, but high HbA1c levels were not. Individuals with diabetes are more likely to be treated surgically for CTS than individuals without diabetes. Individuals with type 1 diabetes are more likely to be treated surgically for CTS than individuals with type 2 diabetes.

Prevalence and Awareness of Carpal Tunnel Syndrome Among Adults in Tabuk City of Saudi Arabia: A Cross-Sectional Study

Background Carpal Tunnel Syndrome (CTS) is a condition when the median nerve is entrapped and compressed within the wrist. It significantly affects the quality of life and work productivity of the affected individuals. Aim This study aimed to assess the prevalence of CTS and the risk factors associated with this condition among the general population in Tabuk City, Saudi Arabia, and to explore their knowledge of the causes, manifestations, and treatment options. Methods This cross-sectional study included male and female adult residents of Tabuk City aged 18 years and above who agreed to participate in the study. Data were collected using an online, self-administered questionnaire that was distributed to the public using different social media platforms. Results In this study, the prevalence of CTS was 3.4%. The presence of chronic diseases was a significant risk factor for the CTS (p = 0.003). Participants having chronic diseases were 6.370 times more likely to develop CTS (AOR: 6.370, 95% CI: 2.048 to 19.817). The participants had good levels of awareness about the causes (89.3%), clinical manifestations, and treatment of CTS (92.2%). There was a significant association between the level of knowledge about the causes of CTS and gender (p=0.014). Females (74.3%) showed a higher level of knowledge than males (25.7%). As well, the young (18-25) age group (67.9%) was more significantly aware of the causes of CTS in comparison to the other age groups (p=0.023). Conclusion The prevalence of carpal tunnel syndrome among the adult population in Tabuk City, Saudi Arabia, was 3.4%, and the significant underlying risk factors were chronic diseases such as diabetes mellitus, hypothyroidism, and rheumatoid arthritis. The level of awareness of CTS was satisfactory.

SIRT1: a promising therapeutic target in type 2 diabetes mellitus

A significant increase in the worldwide incidence and prevalence of type 2 diabetic mellitus (T2DM) has elevated the need for studies on novel and effective therapeutic strategies. Sirtuin 1 (SIRT1) is an NAD + dependent protein deacetylase with a critical function in the regulation of glucose/lipid metabolism, insulin resistance, inflammation, oxidative stress, and mitochondrial function. SIRT1 is also involved in the regulation of insulin secretion from pancreatic β-cells and protecting these cells from inflammation and oxidative stress-mediated tissue damages. In this regard, major SIRT1 activators have been demonstrated to exert a beneficial impact in reversing T2DM-related complications including cardiomyopathy, nephropathy, retinopathy, and neuropathy, hence treating T2DM. Therefore, an accumulating number of recent studies have investigated the efficacy of targeting SIRT1 as a therapeutic strategy in T2DM. In this review we aimed to discuss the current understanding of the physiological and biological roles of SIRT1, then its implication in the pathogenesis of T2DM, and the therapeutic potential of SIRT1 in combating T2DM.

Posterior Tibial Nerve Ultrasound Assessment of Peripheral Neuropathy in Adults with Type 2 Diabetes Mellitus

Background

Diabetic peripheral neuropathy (DPN) is a common and debilitating complication of type 2 diabetes mellitus (T2DM). Early detection and prompt institution of appropriate therapy could prevent undesirable outcomes such as paresthesia, pain, and amputation. Although the gold standard for diagnosing DPN is nerve conduction studies, high-resolution peripheral nerve ultrasonography may serve as a noninvasive and low-cost alternative for diagnosing and staging DPN. This study investigated the clinical utility of sonographic posterior tibial nerve cross-sectional area (PTN CSA) for diagnosing DPN in individuals with T2DM.

Methods

Eighty consecutive adults with T2DM and 80 age-/sex-matched controls were recruited. Clinical information was obtained, including symptoms, disease duration, Toronto clinical neuropathy score (TCNS), and biochemical parameters. The left PTN CSA at 1 cm, 3 cm, and 5 cm above the medial malleolus (MM) was measured with a high-frequency ultrasound transducer and compared to the detection of DPN using the TCNS.

Results

Based on the TCNS, 58 (72.5%) of the T2DM group had DPN. Of these, 14 (24.1%), 16 (27.6%), and 28 (48.3%) participants had mild, moderate, and severe DPN, respectively. All the mean PTN CSA (aggregate, 1 cm, 3 cm, and 5 cm above MM) of the participants with T2DM and DPN (T2DM-DPN) were significantly higher than those of T2DM without DPN (WDPN) and controls. All the PTN CSA increased significantly with increasing severity of DPN. The PTN CSA at 3 and 5 cm levels correlated weakly but significantly with fasting plasma glucose and glycated hemoglobin levels.

Conclusion

The PTN CSA is significantly larger in T2DM-DPN than in T2DM-WDPN and healthy controls. PTN ultrasonography can be an additional tool for screening DPN in patients with T2DM.

Foot drop in children with newly diagnosed type 1 diabetes: three case reports

Summary

The etiology of foot drop is diverse from various diseases to mechanic injuries and includes neuropathy of the peroneal nerve. Peroneal neuropathy might also be one of the forms of diabetic neuropathy, very rarely reported as the first sign of diabetes. We describe three cases of children with newly diagnosed type 1 diabetes (TID) who developed unilateral peroneal nerve palsies and tibial nerve palsies, presenting clinically as a foot drop. In two of our cases, the symptoms of foot drop occurred shortly after starting treatment for severe diabetes ketoacidosis. In the third patient, food drop was a reason for the initial medical consultation, but eventually, TID was diagnosed. The presented cases highlight that neuropathy can be observed not only as a chronic complication of T1D, but it can also appear at the time of disease manifestation. The incorrect position of the lower limb during a keto coma may contribute to the development of neuropathy.

Learning points

Neuropathy can be observed not only as a chronic complication of type 1 diabetes (T1D), but it can also appear at the time of disease manifestation. The incorrect position of the lower limb causing external pressure during a keto coma may contribute to the development of neuropathy. It is important to examine the glycemia in patients with acute peroneal neuropathy, as this kind of peripheral neuropathy can be associated with newly diagnosed T1D. Normalization of glycemia might lead to rapid neuronal recovery.

Multiple Compression Syndromes of the Same Upper Extremity: Prevalence, Risk Factors, and Treatment Outcomes of Concomitant Treatment

PURPOSE

Multiple nerve compression syndromes can co-occur. Little is known about this coexistence, especially about risk factors and surgical outcomes. Therefore, this study aimed to describe the prevalence of multiple nerve compression syndromes in the same arm in a surgical cohort and determine risk factors. Additionally, the surgical outcomes of concomitant treatment were studied.

METHODS

The prevalence of surgically treated multiple nerve compression syndromes within one year was assessed using a review of patients' electronic records. Patient characteristics, comorbidities, and baseline scores of the Boston Carpal Tunnel Questionnaire were considered as risk factors. To determine the treatment outcomes of simultaneous treatment, patients who underwent concomitant carpal tunnel release (CTR) and cubital tunnel release (CubTR) were selected. The treatment outcomes were Boston Carpal Tunnel Questionnaire scores at intake and at 3 and 6 months after the surgery, satisfaction 6 months after the surgery, and return to work within the first year.

RESULTS

A total of 7,867 patients underwent at least one nerve decompression between 2011 and 2021. Of these patients, 2.9% underwent multiple decompressions for the same upper extremity within one year. The risk factors for this were severe symptoms, younger age, and smoking. Furthermore, the treatment outcomes of concomitant CTR and CubTR did not differ from those of CubTR alone. The median time to return to work after concomitant treatment was 6 weeks. Patients who underwent CTR or CubTR alone returned to work after 4 weeks.

CONCLUSIONS

Approximately 3% of the patients who underwent surgical treatment for nerve compression syndrome underwent decompression for another nerve within 1 year. Patients who report severe symptoms at intake, are younger, or smoke are at a greater risk. Patients with carpal and cubital tunnel syndrome may benefit from simultaneous decompression. The time to return to work may be less than if they underwent decompressions in separate procedures, whereas their surgical outcomes are comparable with those of CubTR alone.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Characterizing conventional ankle MRI findings of nerve and muscle changes in diabetic patients: a case-control study

BACKGROUND

Foot and ankle amputation is a feared complication of diabetic neuropathy and diabetes mellitus (DM) accounts for 80% of all in-hospital amputations. Magnetic resonance neurography is an effective tool in characterizing neuromuscular sequelae of the disease. However, conventional ankle MRI is more commonly performed and has not been studied to assess neuromuscular changes of DM.

OBJECTIVE

The objective is to characterize neuromuscular changes of diabetic patients in a case-control study using conventional ankle MRI.

METHODS

Between November 2019 and July 2021, 110 consecutive ankle MRI scans (n = 102 patients) at our county hospital were reviewed and met the inclusion criteria. Patients were divided into two cohorts, diabetic (N = 63) and non-diabetic (N = 39). Demographics, HgbA1c, and reason for MRI study were collected via retrospective chart review. The presence of intramuscular edema-like signal, pattern of the edema, muscle fatty infiltration, and measurements of the cross-sectional area of the posterior, medial, and lateral tibial nerves (PTN, MPN, and LPN) was recorded blinded to the clinical findings by two readers.

RESULTS

Muscle edema-like signal was much more likely to be found in DM (odds ratio 19.5, 95% CI 7.0-54.6, p < 0.001). DM also showed increase of 0.87 in the mean grade of muscle fatty infiltration (p < 0.001). There were higher rates of nerve T2 hyperintensity (odds ratio 14.0, 95% CI 3.1-62.7, p < 0.001) and the measured areas of the PTN, MPN, and LPN were also larger in DM compared to their non-diabetic counterparts (PTN: 0.16 cm² vs. 0.10 cm², p < 0.01; MPN: 0.09 cm² vs. 0.05 cm², p < 0.01; LPN: 0.07 cm² vs. 0.04 cm², p < 0.05).

CONCLUSION

Conventional ankle MRIs can be used to detect DM-related neuromuscular changes.

Magnitude and factors associated with musculoskeletal disorder among patients with diabetes attending chronic care at Arba Minch General Hospital, Arba Minch, southern Ethiopia, 2021: a cross-sectional study

OBJECTIVE

This study aimed to assess the prevalence and determinants of musculoskeletal disorders (MSDs) among patients with diabetes in southern Ethiopia.

DESIGN

Facility-based cross-sectional study.

SETTING

Data collected from 1 March 2021 to 30 August 2021 at Arba Minch General Hospital.

PARTICIPANTS

Three hundred and sixty-five patients with diabetes attending care at Arba Minch General Hospital.

MAIN OUTCOME MEASURES

The magnitude and determinants of the MSDs.

RESULTS

The prevalence of MSDs among patients with diabetes was 23.29% (95% CI 19.00 to 27.76). The likelihood of developing MSDs was 6.8 times higher among women than men (AOR=6.787, 95% CI 2.08 to 22.19). Rural participants were about 2.4 times (AOR=2.38, 95% CI 1.06 to 5.33) more likely to develop MSDs as compared with urban participants. Participants aged &gt;50 years were 5.9 times more likely to develop MSDs as compared with those aged ≤50 years (AOR=5.864, 95% CI 2.663 to 12.914). The odds of developing MSDs was 6.2 times (AOR=6.247, 95% CI 1.158 to 33.702) and 5.5 times (AOR=5.451 95% CI 1.174 to 25.312) higher among participants who attended primary and secondary education as compared with those who attended college and above, respectively. Participants with cardiovascular disease were 3.9 times more likely to develop MSDs as compared with their counterparts (AOR=3.854, 95% CI 1.843 to 8.063).

CONCLUSIONS

This study showed that age, sex, educational status, place of residence and cardiovascular disease were found to be determinants of MSDs. Thus, clinical and public health interventions working on diabetes mellitus should consider these determinants.

Diabetic retinopathy as a predictor for peripheral compression neuropathies, a registry-based study

Diabetes is characterized by hyperglycaemia and entails many complications, including retinopathy and entrapment neuropathies, such as ulnar nerve entrapment (UNE) and carpal tunnel syndrome (CTS). Hyperglycaemia damages the nerves of the retina, as well as peripheral nerves. There is a correlation between entrapment neuropathies and retinopathy in patients with diabetes, but whether patients with diabetic retinopathy are more prone to develop CTS and UNE is uncertain. Hence, the aim was to investigate if retinopathy can be used as a factor predicting the development of CTS and UNE. Data from 95,437 individuals from the National Diabetes Registry were merged with data from the Skåne Healthcare Registry. The population was analysed regarding prevalence of CTS or UNE and retinopathy status. Population characteristics were analysed using the Chi2-test, Student's Independent T-test, and the Mann-Whitney U-test. Two logistic regression models were used to analyse the odds ratio (OR) for development of CTS and UNE depending on retinopathy status, adjusted for possible confounders. Both CTS and UNE were more frequent among those with retinopathy, compared to those without (CTS: 697/10,678 (6.5%) vs. 2756/83,151 (3.3%; p<0.001), (UNE: 131/10,678 (1.2%) vs. 579/83,151 (0.7%; p<0.001)). The OR for developing CTS for individuals with type 1 diabetes and retinopathy was 2.40 (95% CI 2.06-2.81; p<0.001) and of developing UNE was 1.53 (0.96-2.43; p = 0.08). The OR for developing CTS for individuals with type 2 diabetes and retinopathy was 0.93 (0.81-1.08; p = 0.34) and for UNE 1.02 (0.74-1.40; p = 0.90). Diabetic retinopathy is associated with a higher risk of developing CTS and UNE, but the association seems to be mediated by the duration of the diabetes. Higher HbA1c levels, longer diabetes duration and higher BMI are significant risk factors for developing CTS and UNE in type 1 and type 2 diabetes.

Diabetic Mononeuropathies and Diabetic Amyotrophy

This brief review describes the etiology, pathophysiology, clinical features, therapy and prognosis of the diabetic mononeuropathies and diabetic amyotrophy and neuropathic cachexia. Mononeuropathies include cranial neuropathies, of which the oculomotor nerve is most commonly affected, and are thought to be due to microvascular occlusion. Peripherally, entrapment neuropathies occur in both the upper and lower limbs and are due to compression of an already damaged nerve in anatomically restricted channels. Diabetic radiculopathies occur in the dermatones of the thorax and abdomen, mimicking intraabdominal or intrathoracic pathology. I also describe the features of the rare but very distinctive diabetic amyotrophy and neuropathic cachexia. Overall, the prognosis from these conditions is excellent with residual pain or muscle weakness being rare with the exception of diabetic amyotrophy where the prognosis is dependent upon cooperation with intensive rehabilitation. Therapies include "watchful waiting," physical therapy and rarely surgical intervention, which may be urgently needed for nerve decompression and reversal of motor defects.

Tarsal Tunnel Syndrome: An Ultrasound Pictorial Review

Tarsal tunnel syndrome may be idiopathic or may be caused by various conditions: bone disease, thickening of the retinaculum, hematoma, or iatrogenic nerve damage; tendinopathy or tenosynovitis; the presence of supernumerary muscles such as an accessory soleus, peroneocalcaneus internus, or accessory flexor digitorum muscle; bone or joint disorders; expansile tumors or cysts; and venous aneurysm or kinking of the tibial artery. The purpose of this article is to describe and illustrate most of the causes of tarsal tunnel syndrome, as diagnosed by ultrasound, which is a practical, inexpensive method.

Carpal Tunnel Syndrome and Diabetes—A Comprehensive Review

Carpal tunnel syndrome (CTS) is the most common compression neuropathy in the general population and is frequently encountered among individuals with type 1 and 2 diabetes. The reason(s) why a peripheral nerve trunk in individuals with diabetes is more susceptible to nerve compression is still not completely clarified, but both biochemical and structural changes in the peripheral nerve are probably implicated. In particular, individuals with neuropathy, irrespective of aetiology, have a higher risk of peripheral nerve compression disorders, as reflected among individuals with diabetic neuropathy. Diagnosis of CTS in individuals with diabetes should be carefully evaluated; detailed case history, thorough clinical examination, and electrophysiological examination is recommended. Individuals with diabetes and CTS benefit from surgery to the same extent as otherwise healthy individuals with CTS. In the present review, we describe pathophysiological aspects of the nerve compression disorder CTS in relation to diabetes, current data contributing to the explanation of the increased risk for CTS in individuals with diabetes, as well as diagnostic methods, treatment options, and prognosis of CTS in diabetes.

Frequency of carpal tunnel syndrome and hand dysfunction in prediabetes: A cross-sectional, controlled study

Objectives

This study aims to evaluate the frequency of carpal tunnel syndrome (CTS), to investigate the impairment of hand functions in patients with prediabetes (PD), and to compare laboratory findings of PD patients with and without CTS.

Patients and methods

Between June 2018 and January 2019, a total of 115 patients (29 males, 86 females; mean age: 51.4±11.8 years; range, 24 to 78 years) who were recently diagnosed with PD and a total of 54 healthy participants (17 males, 37 females; mean age: 48.4±13.2 years; range, 21 to 78 years) as the control group were included. Demographic and clinical data of the patients including oral glucose tolerance test (OGTT) and glycated hemoglobin (HbA1c) were recorded, and both groups were examined for the presence of CTS. Clinically suspected CTS was confirmed by electrodiagnostic studies. The hand grip strength (HGS) was measured and hand functions were evaluated using the Duruöz Hand Index (DHI).

Results

There were no significant differences in the age, sex, occupation, body mass index (BMI), or insulin resistance between the groups. A total of 24 (20.9%) patients with PD and eight (14.8%) healthy controls had CTS (p=0.349). Hand functions were worse in the PD patients than the control group (p=0.044). Age, occupation, BMI, insulin resistance, OGTT at 0 and 2 h, and HbA1c values were similar between the PD patients with or without CTS.

Conclusion

Our study, for the first time, reveals that CTS is slightly more common and hand functions are impaired in PD compared to the healthy individuals. Based on these findings, we suggest that hand functions should be evaluated in PD patients.

Electrophysiological Study of the Tibial Nerve Across the Tarsal Tunnel in Distal Symmetric Diabetic Polyneuropathy

OBJECTIVE

The aim of the study was to demonstrate abnormalities of motor conduction of the tibial nerve across the tarsal tunnel in type 2 diabetes.

DESIGN

One hundred twenty-four consecutive patients (mean age = 66.6 yrs, 62.1% male) with distal symmetric diabetic polyneuropathy clinically diagnosed were prospectively enrolled. Nerve conduction studies of deep peroneal, tibial, superficial peroneal, medial plantar, and sural nerves and standard needle electromyography in the lower limbs were performed. Demographic, anthropometric, and clinical findings were collected.

RESULTS

Motor conduction velocity of the tibial nerve across tarsal tunnel was slowed in 60.5% of patients; another 4% showed conduction block across tarsal tunnel without reduction of motor conduction velocity. Overall percentage of abnormalities across tarsal tunnel (64.5%) exceeds that of the sensory conduction velocities of proximal sural and superficial peroneal nerves. Abnormal tibial motor conduction velocity across tarsal tunnel represents the most common abnormality among all motor nerve conduction study parameters and significantly correlates with hemoglobin level, diabetic neuropathic index score, and diabetic complications frequency.

CONCLUSIONS

Tibial conduction abnormalities across tarsal tunnel are the most sensitive motor parameter in distal symmetric diabetic polyneuropathy, second only to conduction abnormalities of sensory/mixed distal nerves of the feet. The use of nerve conduction studies across tarsal tunnel of the tibial nerve may be useful in the electrophysiological protocol to confirm the diagnosis of distal symmetric diabetic polyneuropathy.

Carpal Tunnel Syndrome in Diabetes Mellitus

The aim of the present brief review was to discuss carpal tunnel syndrome (CTS) in diabetes mellitus (DM). Generally, CTS is more common in DM, especially in subjects with coexisting diabetic polyneuropathy (DPN) and/or long DM duration. There is no agreement if it is more frequent in type 1 or type 2 DM. The precise underlying mechanisms are not entirely clear but appear to involve hyperglycaemia-induced median nerve oedema, increased sensitivity to exogenous trauma and nerve myelin ischaemia and axonal degeneration. More recently, increased vascular endothelial growth factor (VEGF) and advanced glycation endproducts (AGEs) appear to also play an important role. Median nerve conduction study remains the cornerstone of CTS diagnosis in DM, being more sensitive than clinical examination. CTS can be treated medically or surgically. The latter appears now to be equally effective in subjects with vs. without DM in terms of recurrence rates and quality of life.

Diabetic hand: prevalence and incidence of diabetic hand problems using data from 1.1 million inhabitants in southern Sweden

INTRODUCTION

'The diabetic hand' has traditionally referred to hand complications due to diabetes mellitus (DM), including trigger finger (TF) and Dupuytren's disease (DD). Recent publications have also proposed DM as a risk factor for carpal tunnel syndrome (CTS), ulnar nerve entrapment (UNE), and possibly osteoarthritis (OA) of the first carpometacarpal (CMC-1) joint. This study aimed to explore prevalence and incidence of diabetic hand complications among the population in southern Sweden.

RESEARCH DESIGN AND METHODS

Approximately 1.1 million inhabitants in the region of Skåne aged ≥18 years, whereof 50 000 with DM, were included. Data on incident CTS, UNE, TF, DD, and OA of the CMC-1 joint between 2004 and 2019 were collected from the Skåne Healthcare Register and cross-linked with the National Diabetes Register. Prevalences on December 31, 2019 and 10-year incidence ratios were calculated for type 1 diabetes (T1D), type 2 diabetes (T2D), and the population without DM, stratified for sex. Prevalence ratios and incidence rate ratios with 95% CIs were used for group comparisons.

RESULTS

The prevalences of all five studied diagnoses were higher in both men and women with T1D and T2D (p<0.01) and both T1D and T2D had more concomitant prevalent diagnoses (p<0.0001). The 10-year incidence rates of all diagnoses were higher among T1D and T2D (p<0.0001), except OA of the CMC-1 joint in men with T1D (p=0.055).

CONCLUSIONS

CTS, UNE, and possibly also OA of the CMC-1 joint should be included together with TF and DD when referring to 'the diabetic hand'. The incidence of hand disorders was up to eight times higher among T1D, and both T1D and T2D had more concomitant prevalent diagnoses compared with the population without DM. Future studies should elucidate the pathophysiology behind diabetic hand complications to enable development of effective preventive measures in patients with diabetes.

Risk factors of asymptomatic reduction of motor conduction velocity of the ulnar nerve across the elbow

INTRODUCTION

The aim of the study was to check the risk factors for subjects with motor conduction velocity (MCV) reduction of the ulnar nerve across the elbow without symptoms/signs of ulnar neuropathy at the elbow (UNE) using a database of a previous multicenter case-control study on UNE patients.

METHODS

From the previous database, we extracted all asymptomatic UNE (A-UNE) and matched for age and sex with a control and UNE groups with a ratio of 1:2. Anthropometric factors were measured and all participants filled in a questionnaire on demographic, lifestyle factors, and medical history. One-sample proportion test and univariate and multivariate logistic regression analyses were performed.

RESULTS

We enrolled 64 A-UNE, 124 UNE, and 124 controls (mean age 53 years). There were more males with A-UNE than females (74.2%). The predominantly or exclusively concerned side of A-UNE was the right. Logistic regression showed that A-UNE was associated with diabetes (OR = 2.99, 95% CI = 1.21-7.39) and width of cubital groove (CGW) (OR = 0.89, 95%  CI = 0.81-0.97).

DISCUSSION

Risk factors for A-UNE are different from UNE. The prevalence of right side in A-UNE was not due to particular elbow postures. Diabetes is a risk factor, probably because MCV reduction of the ulnar nerve across the elbow was an early manifestation of asymptomatic polyneuropathy in diabetes. A-UNE is associated with narrow CGW as already demonstrated in UNE, even if the OR was higher in UNE than in A-UNE. Only future longitudinal studies will be able to check whether the A-UNE subjects develop symptoms and signs of true mononeuropathy with time.

Rare diabetic neuropathies: It is not only distal symmetrical polyneuropathy

The prevalence of diabetes mellitus is increasing at an epidemic level, leading to a consequent increase of its chronic complications, including neuropathy. Diabetic neuropathy constitutes a heterogeneous group of disorders with distinct clinical presentations and pathophysiological mechanisms. These distinct forms may be categorised according to their clinical presentation as symmetrical (distal symmetrical polyneuropathy, autonomic and acute sensory neuropathy) and focal or multifocal (radiculoplexus neuropathies, entrapment syndromes, cranial palsies and other mononeuropathies). Additionally, people with diabetes may have neuropathies due to causes other than diabetes. The commonest forms of diabetic neuropathy are distal symmetrical polyneuropathy and autonomic neuropathy. However, clinicians should be aware that people with diabetes may suffer from less common forms of neuropathy and should be able to recognise their symptoms and signs. The recognition of the rare diabetic neuropathies is crucial, as they often lead to different clinical outcomes and require different management. The aim of the present narrative, non-systematic review is to outline the rare types of diabetic neuropathies.

Pathogenesis, diagnosis and clinical management of diabetic sensorimotor peripheral neuropathy

Diabetic sensorimotor peripheral neuropathy (DSPN) is a serious complication of diabetes mellitus and is associated with increased mortality, lower-limb amputations and distressing painful neuropathic symptoms (painful DSPN). Our understanding of the pathophysiology of the disease has largely been derived from animal models, which have identified key potential mechanisms. However, effective therapies in preclinical models have not translated into clinical trials and we have no universally accepted disease-modifying treatments. Moreover, the condition is generally diagnosed late when irreversible nerve damage has already taken place. Innovative point-of-care devices have great potential to enable the early diagnosis of DSPN when the condition might be more amenable to treatment. The management of painful DSPN remains less than optimal; however, studies suggest that a mechanism-based approach might offer an enhanced benefit in certain pain phenotypes. The management of patients with DSPN involves the control of individualized cardiometabolic targets, a multidisciplinary approach aimed at the prevention and management of foot complications, and the timely diagnosis and management of neuropathic pain. Here, we discuss the latest advances in the mechanisms of DSPN and painful DSPN, originating both from the periphery and the central nervous system, as well as the emerging diagnostics and treatments.

Lateral Distractor Use During Internal Fixation of Tibial Plateau Fractures Has a Minimal Risk of Iatrogenic Peroneal Nerve Palsy

OBJECTIVES

To determine the incidence of iatrogenic peroneal nerve palsy after application of an intraoperative lateral distractor during open reduction and internal fixation of tibial plateau fractures.

DESIGN

Retrospective review.

SETTING

Single academic Level I trauma center.

PATIENTS

One hundred forty-seven patients met criteria and were included in the study.

INTERVENTION

Patients with unicondylar and bicondylar tibial plateau fractures underwent open reduction and internal fixation and received application of an intraoperative lateral distractor to aid in visualization and reduction of the impacted lateral plateau.

MAIN OUTCOME MEASUREMENTS

Incidence of iatrogenic peroneal nerve palsy.

RESULTS

There was a 2.0% incidence of iatrogenic peroneal nerve symptoms (3 of 147 patients), most of which were incomplete sensory deficits. There was no association with staged external fixation, regional anesthesia, or tourniquet use.

CONCLUSION

Use of an intraoperative lateral distractor is safe and has a low incidence of iatrogenic peroneal nerve palsy if applied carefully.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Free serum sorbitol and its interaction with caffeine: A suggestive approach for plausible remediation of diabetic neuropathy

The measure of sorbitol in serum can act as a good indicator in the monitoring of the diabetic complications. To analyze the sorbitol level in serum medium, fluorometric enzymatic assay was performed. To remove the excess sorbitol from the body, proposed binding of sorbitol with caffeine was investigated. Their interaction in serum medium was studied and established by UV-Vis, fluorescence spectrophotometry, and time-correlated single photon counting (TCSPC). The linear calibration of sorbitol (in the range 10-50 mM) was done using UV-Vis spectrophotometry. Time scan experiments furnished the reaction rate of sorbitol assayed solution as well as sorbitol-caffeine complex as 0.021 min^-1 and 0.018 min^-1 , respectively. A sudden drop was observed in the fluorescence lifetime of reduced nicotinamide adenine dinucleotide (NADH) present in sorbitol assayed solution upon complexation with caffeine, that is, from 1.774 × 10^-09 to 1.23 × 10^-10 Sec, which indicates the hindrance in the formation of NADH and the probable formation of some other species. Isothermal titration calorimetric experiments clearly indicate the number of binding sites (i.e., 3.89, 1.40, and 2.07) that exist between sorbitol and caffeine at the complexation ratio of 1:1.2, 1:1.5, and 1:3. The present method can be helpful in pharmacological and therapeutic studies of sorbitol using caffeine for treating diabetic neuropathy.

Utility of nerve ultrasound in ulnar neuropathy with abnormal non-localizing electrophysiology in diabetes mellitus

We studied the utility of ultrasound in the diagnostic workup of ulnar neuropathy with abnormal non-localizing electrophysiology (NL-UN) in patients with diabetes. Eighteen ulnar nerves (15 patients) were scanned from wrist to mid-upper arm. Ultrasound showed: (a) focal nerve enlargement at the elbow (8/18 nerves), either alone (6) or superimposed upon diffuse nerve abnormality (2); (b) diffuse nerve enlargement without focal abnormality (8/18); (c) segmental abnormality in upper-arm or forearm without extrinsic nerve compression (2/18). This study shows a pivotal role for ultrasound in the classification of NL-UN in patients with diabetes, which can facilitate critical therapeutic decisions.

Is There an Association between Diabetes and Neck and Back Pain? Results of a Case-Control Study

We aimed to assess if subjects with diabetes exhibit higher prevalence of chronic back pain than age-sex-province of residence-matched non-diabetic controls. We also aimed to identify predictors for chronic neck pain (CNP) or chronic low back pain (CLBP) among subjects with diabetes. A case control study was conducted using data obtained from the Spanish National Health Survey 2017. Multivariable conditional and unconditional logistic regression models were constructed. A total of 2095 diabetes sufferers and 2095 non-diabetic matched controls were analyzed. The prevalence of CNP and CLBP was 27.3% and 34.8%, respectively, in diabetes sufferers and 22.1% and 29.0% in non-diabetes controls (both, p < 0.001). After multivariable analysis, the ORs showed significantly higher adjusted risk of CNP (OR 1.34; 95% CI 1.19–1.51) and CLBP (OR 1.19, 95% CI 1.09–1.31) in diabetes cases. Diabetes sufferers with CNP or CLBP showed higher use of pain medication and higher prevalence of migraine/frequent headache than controls. Female sex, worse self-rated health and use of pain medication were predictors for CNP and CLBP in subjects with diabetes. CNP and CLBP are significantly more prevalent in diabetes sufferers than in controls. Current results can help to design better preventive and educational strategies for these highly prevalent and burdensome pains among diabetic patients.

Clinical spectrum and diagnosis of diabetic neuropathies

Neuropathy is the most prevalent microvascular complication of diabetes mellitus; it encompasses distal symmetric polyneuropathy, autonomic neuropathy, radiculoplexus neuropathy, mononeuropathy, and treatment-induced neuropathy. The prevalence rate of diabetic neuropathy in Korea was reported to be approximately 43%, which is similar to rates in other countries. However, the precise pathogenic mechanism underlying diabetic neuropathy is still obscure, and many clinical trials have failed to develop methods to prevent or reduce the progression of diabetic neuropathy. Nevertheless, early diagnosis and proper management of diabetic neuropathy are essential to alleviate disabling symptoms and to improve the quality of life of patients. This review discusses clinical manifestations and classification of diabetic neuropathies, bedside neurological examination, and electrophysiological tests.

Diabetic Distal Symmetrical Polyneuropathy: Correlation of Clinical, Laboratory, and Electrophysiologic Studies in Patients with Type 2 Diabetes Mellitus

This cross-sectional study is aimed at determining the prevalence of distal symmetrical polyneuropathy (DSPN) and diabetic peripheral neuropathic pain (DPNP) in participants with type 2 diabetes mellitus (T2DM); finding the risk factors for DSPN and DPNP via biochemical tests; and correlating DSPN and DPNP with the results of electrophysiologic studies, quantitative sensory tests, and neurologic examination. The 145 participants with T2DM enrolled were divided into the DSPN (abnormal nerve conduction studies (NCS) with signs of polyneuropathy), subclinical DSPN (abnormal NCS without signs of polyneuropathy), minimal DSPN (normal NCS with signs of polyneuropathy), and no DSPN groups. The biochemical risk factors of diabetic peripheral neuropathy were investigated. Neurologic examinations, laboratory tests, NCS, vibration threshold tests, and thermal threshold tests were conducted. The modified Michigan Neuropathy Screening Instrument (mMNSI) and Douleur Neuropathique 4 were used to evaluate the severity of DSPN and DPNP, respectively. In all, 30% of participants had DSPN and 11% had DPNP. DSPN correlated strongly with male gender and higher glycohaemoglobin levels; NCS abnormality correlated with higher glycohaemoglobin levels; DSPN severity correlated with NCS of each stimulating nerve. DPNP commonly occurred with clinical and electrophysiologic evidence of DSPN. Symptomatic diabetic polyneuropathy significantly correlated with longer disease duration, higher glycohaemoglobin levels, and abnormal vibration tests. The thermal threshold test combined with nerve conduction tests could detect most of the patients with DSPN, subclinical DSPN, and minimal DSPN. Poor diabetic control was independently associated with the development of DSPN. DPNP was associated with DSPN. The combination of thermal threshold tests with NCS can potentially provide the diagnosis of DSPN.

Carpal tunnel syndrome and exposure to work-related biomechanical stressors and chemicals: Findings from the Constances cohort

Objective

To investigate the effects of co-exposure to biomechanical wrist stressors and chemicals on the risk of CTS in a large cohort of French workers.

Methods

Prospective study using the data collected at baseline and at the first 12 month-follow-up for the 18,018 participants included in the population-based Constances cohort between 2012 and 2015. CTS at follow-up and exposure to biomechanical wrist stressors and chemicals at baseline were assessed using a self-administered questionnaire. Associations between CTS and co-exposure to biomechanical wrist stressors and chemicals were studied using multivariate logistic regression models, adjusted for personal/medical factors.

Results

184 men (2.1%, 95%CI 1.8–2.4) and 331 women (3.6%, 3.2–3.9) free from chronic hand symptoms at baseline declared suffering from unilateral/bilateral CTS at follow-up. A potentiating effect of co-exposure to biomechanical wrist stressors and chemicals on the risk of CTS was found for both genders, with higher OR in the co-exposure group (OR = 3.38 [2.29–5.01] in men and OR = 4.12 [2.73–6.21] in women) than in the biomechanical exposure group (OR = 2.14 [1.51–3.03] in men and OR = 2.19 [1.72–2.78] in women) compared to no exposure group.

Conclusions

The study showed an association between CTS and co-exposure to biomechanical wrist stressors and chemicals, after adjustment for the main personal and medical factors. This finding should be confirmed using more objective case definition of CTS and assessment of the chemical exposure before drawing conclusions on the possible synergistic effects of mechanical stressors and chemical on the median nerve.

Comparison of two manual therapy techniques in patients with carpal tunnel syndrome: A randomized clinical trial

Background

Manual therapy techniques are part of physiotherapy treatment of carpal tunnel syndrome (CTS) which are classified into two groups including nerve mobilization and mechanical interface mobilization. The aim of the study was to find which manual therapy method-technique directed to mechanical interface and nerve mobilization-has superior beneficial effects on clinical and electrophysiological findings in conservative management of patients with CTS.

Methods

Thirty patients with CTS participated into two groups namely: mechanical interface and nerve mobilization in this randomized clinical trial. The intervention was performed three times weekly for 4 weeks. Mechanical interface mobilization was directed to structures around the median nerve at the forearm and wrist. Techniques of median nerve gliding and tension were used in the nerve mobilization group. The outcome measures included visual analogue scale (VAS), symptom severity scale (SSS), hand functional status scale (FSS) and motor and sensory distal latencies of median nerve. Paired t-test and ANCOVA were used for statistical analysis.

Results

At the end of the 4^th week of the treatment, the mean of VAS, SSS and FSS significantly improved in both groups (p<0.05), but the difference was not significant between the two groups (P>0.05). Although the mean of motor and sensory distal latencies of median nerve at the end of the treatment period only improved in the nerve mobilization group (p<0.05), the difference was not significant between the two groups (P>0.05).

Conclusion

Mechanical interface mobilization and nerve mobilization techniques are not superior to each other in reducing pain and improving hand symptoms and functional status.

Carpal Tunnel Decompression Surgery Outcome and Effect of Diabetes

OBJECTIVE

The benefits of carpal tunnel decompressive surgery (CTDS) among diabetic patients with carpal tunnel syndrome (CTS) were previously investigated through comparing the outcome before and after CTDS, and in comparison to nondiabetic CTS. We sought to investigate if diabetes mitigates the benefits of CTDS compared to not receiving CTDS.

METHODS

In this retrospective study, we compared the risk of reporting any unfavorable outcomes among CTS patients (diabetic and nondiabetic) who underwent CTDS versus no CTDS after controlling for diabetes. We also compared the risk of reporting any unfavorable outcomes (waking up at night, pain during the day or during daily activities, or hand weakness) among diabetic CTS patients who underwent CTDS versus no CTDS after controlling for severity.

RESULTS

We included 207 patients; of these, 105 patients had CTDS and 102 did not. There were 60 diabetic and 147 nondiabetic patients. The risk of any unfavorable outcomes was reduced by CTDS from 83.3 to 66.6%, with an odds ratio (OR), after controlling for diabetes, of 0.39 (95% confidence interval [CI] 0.20-0.78). Among diabetic patients, there was no difference between the CTDS and non-CTDS groups in the risk of reporting any unfavorable outcomes; however, after adjustment for severity, the risk of hand weakness was less with CTDS, with an OR of 0.13 (95% CI 0.02-0.86).

CONCLUSION

Diabetes did not mitigate the benefits of CTDS. CTDS may prevent hand weakness among diabetic CTS patients.

Electrophysiological and phenotypic profiles of taxane-induced neuropathy

OBJECTIVE

To comprehensively describe patient-reported, functional and neurophysiological outcomes to elucidate the phenotypic profile of taxane-induced neuropathy.

METHODS

Taxane-treated patients (n = 47) completed cross-sectional bilateral clinical and sensory assessments and nerve conduction studies. Patients reported symptom severity via Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity (FACT/GOG-Ntx13) questionnaire.

RESULTS

Symptoms of neuropathy were reported by 81% of patients. On clinical examination, 62% had 2 or more abnormalities, with 20% indicating significant symptomatic and objective neuropathy. Nerve conduction studies were consistent with a sensory predominant axonal neuropathy. However, features more typical of entrapment neuropathy were also present in > 50%, which were not associated with overall severity of chemotherapy-induced peripheral neuropathy (CIPN) or clinical risk factors.

CONCLUSIONS

There is considerable variation in CIPN phenotypes associated with taxane-treatment. Understanding their clinical associations may assist in identification of patients at risk of severe neurotoxicity. This would enable treatment modification decisions but also limit early cessation of effective anti-cancer treatment in patients with less severe neurological sequelae.

SIGNIFICANCE

Understanding the CIPN phenotype may inform treatment decisions which could impact clinical and survival outcomes.

Diabetes mellitus as a risk factor for compression neuropathy: a longitudinal cohort study from southern Sweden

INTRODUCTION

Compression neuropathies (CN) in the upper extremity, the most common being carpal tunnel syndrome (CTS) and ulnar nerve entrapment (UNE), are frequent among patients with diabetes mellitus (DM). Earlier studies have shown contradicting results regarding DM as a risk factor for CN. Thus, the aim of the present population-based, longitudinal study was to explore potential associations between DM, CTS, and UNE during long-term follow-up.

RESEARCH DESIGN AND METHODS

A total of 30 466 participants aged 46-73 years, included in the population-based Malmö Diet and Cancer Study during 1991-1996, were followed up in Swedish national registries regarding incident CTS and UNE until 2016. Associations between prevalent DM at baseline and incident CTS or UNE were calculated using Cox proportional hazard models, adjusted for baseline confounders, such as sex, age at study entry, smoking, hypertension, use of antihypertensive treatment, alcohol consumption, and body mass index (BMI). HbA1c and fasting plasma glucose levels had been measured at baseline in a subgroup of 5508 participants and were related to incident CTS and UNE in age and sex-adjusted binary logistic regression models.

RESULTS

A total of 1081 participants developed CTS and 223 participants developed UNE during a median follow-up of 21 years. Participants with incident CTS or UNE had higher prevalence of DM and higher BMI at baseline. Using multivariate Cox regression models, prevalent DM at baseline was independently associated with both incident CTS (HR 2.10; 95% CI 1.65 to 2.70, p<0.0001) and incident UNE (HR 2.20; 95% CI 1.30 to 3.74, p=0.003). Higher levels of HbA1c and plasma glucose were associated with an increased risk for CTS, but not for UNE.

CONCLUSION

This study establishes DM as a major risk factor in the development of both CTS and UNE. Furthermore, a higher BMI is associated with both CTS and UNE. Finally, hyperglycemia seems to affect the median and ulnar nerves differently.

Distribution of Highly Prevalent Musculoskeletal Disorders and Their Association With Diabetes Complications in a Population of 140 Individuals With Type 1 Diabetes: A Retrospective Study in a French Diabetes Center

Although they are usually not considered to be diabetes complications, musculoskeletal disorders (MSKDs) are common in individuals with type 1 or type 2 diabetes and can strongly interfere with daily diabetes care, especially in people using diabetes technologies. The authors of this retrospective study in a population of 140 patients with type 1 diabetes report the distribution of subtypes of MSKDs and speculate about the mechanisms involved. The authors emphasize the need for multidisciplinary care involving not only the diabetes care team but also orthopedic surgeons. This report should lead to large, prospective studies to increase knowledge about these under-studied complications.

Ulnar Nerve Entrapment in Diabetes: Patient-reported Outcome after Surgery in National Quality Registries

BACKGROUND

Ulnar nerve entrapment at the elbow (UNE) is overrepresented in patients with diabetes, but the outcome of surgery is unknown. We aimed to evaluate patient-reported outcome in patients with and without diabetes, and to assess potential sex differences and compare surgical treatment methods.

METHODS

Data on patients operated for UNE (2010-2016, n = 1354) from the Swedish National Registry for Hand Surgery were linked to the Swedish National Diabetes Register. Symptoms were assessed preoperatively (n = 389), and 3 (n = 283), and at 12 months postoperatively (n = 267) by QuickDASH and HQ-8 (specific hand surgery questionnaire-8 questions). Only simple decompressions were included when comparing groups.

RESULTS

Men with diabetes reported higher postoperative QuickDASH scores than men without diabetes. Women scored their disability higher than men on all time-points in QuickDASH, but showed larger improvement between preoperative and 12 months postoperative values. Patients operated with transposition scored 10.8 points higher on QuickDASH than patients who had simple decompression at 12 months (95% confidence interval 1.98-19.6).

CONCLUSIONS

Women with diabetes benefit from simple decompression for UNE to the same extent as women without diabetes. Men with diabetes risk not to benefit from simple decompression as much as women do. Ulnar nerve transposition had a higher risk of residual symptoms compared to simple decompression.

Carpal Tunnel Syndrome Among Male French Farmers and Agricultural Workers: Is It Only Associated With Physical Exposure?

Background

Exploratory study to investigate whether co-exposure to physical wrist stressors and chemicals is associated with carpal tunnel syndrome (CTS) in French male farmers and agricultural workers.

Methods

Cross-sectional study of 711 men aged 30–65 years and working as either farmers or agricultural workers in 2009–2010 within a cohort covered by the French Agricultural Workers' and Farmers' Mutual Benefit Fund. CTS and exposure to physical wrist stressors and chemicals were assessed using a self-administered questionnaire. Associations between CTS and personal/medical factors, exposure to physical wrist stressors, exposure to chemicals, and co-exposure to physical wrist stressors and chemicals were studied using multivariate logistic regression models.

Results

Forty-four men {5.6% [95% confidence interval (CI) 4.0–7.7]} reported that they had suffered from unilateral/bilateral CTS during the last 12 months. CTS was associated with age, current smoking [odds ratio (OR) = 2.1 (1.0–4.5)], and exposure to physical wrist stressors [OR = 2.6 (1.1–5.9)]. An association was found between CTS and co-exposure to physical wrist stressors and chemicals [OR = 3.3 (0.8–14.3), p = 0.044] in comparison with the no-exposure group.

Conclusions

This exploratory study shows an association of CTS with exposure to biomechanical wrist stressors in male farmers and agricultural workers and suggests an association of CTS with co-exposure to physical wrist stressors and chemicals. Owing to the limitations of the study, this result must be confirmed by a prospective study with objective assessments of the outcome and exposure before drawing conclusions on the possible synergistic effects of mechanical stressors and chemicals on the impairment of the median nerve.

Occupational co-exposure to biomechanical factors and neurotoxic chemicals in a representative sample of French employees

Objectives

Musculoskeletal disorders, mainly carpal tunnel syndrome, represent a leading cause of compensation claims of workers worldwide. Despite this, and the fact that occupational exposures to biomechanical factors and neurotoxic chemicals have been individually associated with peripheral nerve damage, the prevalence of occupational co‐exposure to biomechanical factors and neurotoxic chemicals has rarely been explored. Therefore, our aim was to assess the prevalence of occupational co‐exposure to biomechanical factors and neurotoxic chemicals in a national representative sample of the French working population.

Methods

The study was based on the French representative cross‐sectional survey SUMER 2010. A total of 47 983 employees who had worked in their current job for at least one year were included. Occupational exposure to biomechanical factors and neurotoxic chemicals within the previous week of work were assessed using a questionnaire during face‐to‐face interviews with occupational physicians.

Results

Approximately 5% of male employees and 1% of female employees were co‐exposed to biomechanical factors and neurotoxic chemicals. This prevalence was up to 10% among male blue‐collar workers and 13%, 8%, and 6%, respectively, among male employees in the construction, agriculture, and industry sectors. Male employees under 30 years old, in apprenticeships, and working in small companies were more co‐exposed to biomechanical factors and neurotoxic chemicals than their counterparts.

Conclusions

Occupational co‐exposure to biomechanical factors and neurotoxic chemicals was observed in a significant proportion of French male employees, suggesting that further studies are required to investigate its potential adverse effects on peripheral neuropathies.

Open carpal tunnel release and diabetes: a retrospective study using PROMs and national quality registries

OBJECTIVES

To study patient-reported outcome after open carpal tunnel release (OCTR) for carpal tunnel syndrome (CTS) in patients with or without diabetes using national healthcare quality registries.

DESIGN

Retrospective cohort study.

SETTING

Data from the Swedish National Quality Registry for Hand Surgery (HAKIR; www.hakir.se) were linked to data from the Swedish National Diabetes Register (NDR; www.ndr.nu).

PARTICIPANTS

We identified 9049 patients (10 770 hands) operated for CTS during the inclusion period (2010-2016).

PRIMARY OUTCOME MEASURES

Patient-reported outcome measures were analysed before surgery and at 3 and 12 months postoperatively using the QuickDASH as well as the HAKIR questionnaire with eight questions on hand symptoms and disability.

RESULTS

Patients with diabetes (n=1508; 14%) scored higher in the QuickDASH both preoperatively and postoperatively than patients without diabetes, but the total score change between preoperative and postoperative QuickDASH was equal between patients with and without diabetes. The results did not differ between patients with type 1 or type 2 diabetes. Patients with diabetic retinopathy scored higher in QuickDASH at 3 months postoperatively than patients with diabetes without retinopathy. In the regression analysis, diabetes was associated with more residual symptoms at 3 and 12 months postoperatively.

CONCLUSIONS

Patients with diabetes experience more symptoms both before and after OCTR, but can expect the same relative improvement from surgery as patients without diabetes . Patients with retinopathy, as a proxy for neuropathy, may need longer time for symptoms to resolve after OCTR. Smoking, older age, higher HbA1c levels and receiving a diabetes diagnosis after surgery were associated with more residual symptoms following OCTR.

CHEIROARTHROPATHY: A COMMON DISORDER IN PATIENTS IN THE T1D EXCHANGE

OBJECTIVE

Diabetic cheiroarthropathy is a long-term complication of diabetes that causes significant morbidity and can impair functional abilities. It has not been well studied in individuals with type 1 diabetes (T1D). The T1D Exchange registry provided an opportunity to assess the frequency of cheiroarthropathy and related characteristics.

METHODS

An internet-based survey was sent to 6,199 registry participants ≥18 years old, with 1,911 (31%) responding (62% female, 90% non-Hispanic White, mean age 40 years, median diabetes duration 20 years, mean glycated hemoglobin [HbA1c] 7.7% [61 mmol/mol]).

RESULTS

A total of 586 (31%) adults reported a diagnosis of ≥1 upper extremity disorder: 293 (15%) reported frozen shoulder, 293 (15%) trigger finger, 261 (14%) carpal tunnel, and 92 (5%) Dupuytren contracture, with 281 (15%) reporting ≥2 disorders. Those with upper extremity joint disorders were more likely older ( P<.001) and had longer duration of diabetes ( P<.001) than those without. HbA1c levels at the time of survey completion were 7.6% in participants with cheiroarthropathy versus 7.8% (62 mmol/mol) in participants without cheiroarthropathy.

CONCLUSION

Cheiroarthropathy is common in adults with T1D. Additional research is needed to understand the pathogenesis and risk factors for this disorder. Standards of care for early recognition and treatment of diabetic cheiroarthropathy are also needed, particularly for adults with long-term diabetes. Improved awareness of cheiroarthropathy signs and symptoms of is needed so that patients can be identified and seek treatment before the condition causes disability.

ABBREVIATIONS

BMI = body mass index; CGM = continuous glucose monitor; DCCT/EDIC = Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications; HbA1C = glycated hemoglobin; T1D = type 1 diabetes; T2D = type 2 diabetes.

Electrodiagnosis in the Patient with Metabolic Syndrome: Adding Value to Patient Care

Patients with metabolic syndrome are at increased risk of peripheral neuropathy; entrapment neuropathies, such as carpal tunnel syndrome; and spine disease that can lead to radiculopathy or spinal stenosis. Electrodiagnostic studies are a valuable part of patient care in this population. They can confirm suspected diagnoses, uncover additional conditions, and lead to the diagnosis of other causes of neuropathy that require treatment. By assessing the severity of neuropathy, patients at high risk for falls, functional decline, and foot ulcers are identified to guide prevention, treatment, and patient education.

Ultrasonographic reference values for the deep branch of the radial nerve at the arcade of Frohse

PURPOSE

The deep branch of the radial nerve (DBRN) enters the forearm as it passes under the arcade of Frohse. This is the most common entrapment site of the DBRN in the forearm. In this study, we investigated the ultrasonographic reference values for the diameters and cross-sectional area (CSA) of the DBRN at the level of the arcade of Frohse in a healthy sample of the population.

METHODS

Sixty-five healthy Caucasian volunteers (130 nerves) were recruited for this study. The reference range [mean ± 2 standard deviations (SD); 2.5th-97.5th quintiles] and the upper limit of the side-to-side difference were determined. The effects of age, gender, handedness, height, and body mass index were examined.

RESULTS

The mean age was 41.8 ± 11.2 years (range 18-75 years). The mean ± 2SD of the CSA was 0.50-1.42 mm². The upper limit of the normal side-to-side difference was 0.35 mm². The differences between males and females and between the dominant and non-dominant arms were not significant. The mean anteroposterior and transverse diameters were 0.83 ± 0.13 and 1.23 ± 0.29 mm, respectively. A significant correlation between the dominant-side CSA and age (r = 0.41; p < 0.001) was observed. The correlations between CSA and height (r = 0.19; p = 0.12) and body mass index (r = 0.22; p = 0.07) were not significant.

CONCLUSION

The measurements obtained in this study are valuable for examining DBRN pathologies using high-frequency ultrasound. The findings showed that age was associated with the DBRN CSA, while gender, height, and body mass index were not.

[Diabetic and non-diabetic neuropathies in patients with diabetes mellitus]

Diabetic polyneuropathy is the most often complication of diabetes mellitus. However, patients with diabetes may have other neuropathies, which need to be recognized and treated. Chronic nnflammatory demyelinating polyneuropathy is the most common non-diabetic polyneuropathy in patients with diabetes. The article discusses the classification, clinical features of diabetic and nondiabetic polyneuropathies, modern methods of diagnosis and approaches to treatment.

Ultrasonographic reference values for the median nerve at the level of pronator teres muscle

PURPOSE

The purpose of this study was to investigate the ultrasonographic reference values for diameters and cross-sectional area (CSA) of the median nerve between the two heads of the pronator teres muscle in healthy population as well as to correlate the findings with height, weight, sex and age.

METHODS

Fifty-five healthy Caucasian volunteers (110 median nerves) were included in this study. The reference range (mean ± 2 standard deviations; 2.5th-97.5th quintiles) and the upper limit of side-to-side difference of the median nerve between the two heads of the pronator teres muscle were investigated using high-frequency ultrasound. The effects of age, sex, height, handedness, and body mass index (BMI) were examined.

RESULTS

The mean age was 39.4 ± 10.6 years (range 18-75 years). The mean ± 2SD of the median CSA was 4.9-12.9 mm². The upper limit of normal side-to-side difference was 3.0 mm². The differences between genders and between the dominant and non-dominant hands were not significant. The mean antero-posterior and transverse diameters were 7.2 ± 1.5 and 10.7 ± 2.4 mm, respectively. Significant correlations were observed between the dominant-side CSA and BMI (r = 0.33; p = 0.01) and age (r = 0.31; p = 0.02). The correlation between the CSA and height (r = 0.19; p = 0.16) was not significant.

CONCLUSIONS

The measurements obtained in this study are of importance for examining median nerve entrapments in the forearm using high-frequency ultrasound. Age and BMI showed to be correlated with median nerve CSA; while gender and height were not.

R(+)-Thioctic Acid Effects on Oxidative Stress and Peripheral Neuropathy in Type II Diabetic Patients: Preliminary Results by Electron Paramagnetic Resonance and Electroneurography

Objectives

Diabetic neuropathy is the most common complication of diabetes. The idea of alterations in energy metabolism in diabetes is emerging. The biogenic antioxidant R(+)-thioctic acid has been successfully used in the treatment of diabetic polyneuropathic (DPN) patients.

Methods

The effects of R(+)-thioctic acid (1 tablet, 1.6 g) administration were evaluated in 12 DPN patients at baseline and at 15, 30, 60, and 120 administration days throughout the assessment of oxidative stress (OxS); ROS production rate by electron paramagnetic resonance (EPR) technique; and oxidative damage biomarkers (thiobarbituric acid reactive substances (TBARS) and protein carbonyls (PC)), electroneurography (ENG) and visual analogue scale.

Results

Supplementation induced significant changes (p < 0.05) at 30 and 60 days. ROS production rate up to -16%; TBARS (-31%), PC (-38%), and TAC up to +48%. Motor nerve conduction velocity in SPE and ulnar nerves (+22% and +16%) and sensor conduction velocity in sural and median nerves (+22% and +5%). Patients reported a general wellness sensation improvement (+35%) at 30 days: lower limb pain sensation (-40%) and upper limbs (-23%).

Conclusion

The results strongly indicate that an increased antioxidant capacity plays an important role in OxS, nerve conduction velocity, pain, and general wellness improvement. Nevertheless, the effects of the antioxidant compound were found positive up to 60 days. Then, a hormesis effect was observed. Novelty of the research would be a challenge for investigators to carefully address issues, including dose range factors, appropriate administration time, and targeting population to counteract possible "boomerang effects." The great number of monitored parameters would firmly stress these conclusions.

The feasibility of using high-resolution ultrasonography to assess ulnar nerve in patients with diabetes mellitus

OBJECTIVE

The aim of this study was to investigate the usefulness of high-resolution ultrasonography for the diagnosis of polyneuropathy in diabetes mellitus patients by the examination of the ulnar nerves.

METHOD

We recruited 100 healthy age-matched volunteers (50 women and 50 men) with 200 arms without diabetes or cubital tunnel syndrome as the control group. We assessed the upper limbs of 100 diabetes mellitus patients (45 women and 55 men), 40 of whom had electrophysiologically confirmed diabetic peripheral neuropathy and 60 had no diabetic peripheral neuropathy in the upper limbs. Age, sex, height and weight were recorded and the cross-sectional area of the ulnar nerve was measured at every predetermined site.

RESULTS

The cross-sectional area of the ulnar nerve was measured at six sites (mid-humerus, inlet of the cubital tunnel, outlet of the cubital tunnel, upon the medial epicondyle, 6 cm upon the wrist crease and Guyon tunnel). The ulnar nerve in two measuring sites (mid-humerus, upon the medial epicondyle) in the control group showed a statistical difference between men and women (p < 0.05). There was no statistical difference in the cross-sectional area in the control group when dominant and non-dominant arms were compared. The cross-sectional area was larger in the diabetic peripheral neuropathy group in three sites (inlet of the cubital tunnel, outlet of the cubital tunnel, Guyon tunnel) compared with those in the control group.

CONCLUSION

High-resolution ultrasonography may be helpful in the early diagnosis of peripheral neuropathy in diabetic patients.